Dvorak – it has to be based on timing and complexity of each recovery – case-by-case basis

Putukian – if we can’t agree on dx how can we agree on a number

Overall theme is it is individualized, not all concussions are the same (Cantu)

Who is best qualified to make the sideline decision?

Cantu – multiple members working under a physician can make the call

Herring – concerning to him that some information is intrinsic to doctors so need to be careful

better question is who best qualified – person with most experience

Dvorak – looking at spectrum of games played, doctors are best qualified in most instances, but are they there in all matches? We should aim all this to the “grass roots” as the professional level there is more than adequate coverage.

comedy about football versus american football

Ellenbogen – those that know the athletes should be making the decision, maybe a parent in youth sports, or athletic trainers, understanding the patients baseline is important

Putukian – balancing act, in a perfect world its a team approach (Athletic Trainer mention), and she says in the US the athletic trainer should be making the decisions on the sidelines…

Aubrey – Hockey Canada has a safety person (volunteer) in lieu of an athletic trainer

Cantu – brings up possibly training school teachers in concussion

Herring – if you are team physician do you need someone else to make the decision if you are on the sideline? Panel – no

Is there a role for grading concussions?

Cantu – not perfect, but informing patient is important about severity and duration of recovery, after the fact

McCrory – we have moved from grading, look at the recovery – perhaps look at the SCAT/serial testing

Putukian – looking at history is more important than arbitrary “grade”

Herring – may help with continual care from one place to another, but again important to understand history

Should we be returning on the same day of concussion?

Aubrey – what about the NHL player in the playoffs (rhetorical question)

Cantu – no once recognized

McCrory – what about the players that clear the SCAT, so no concussion, but you know something is amiss?

Putukian – example of hockey player with delayed symptoms

McCrory – concussion is often an evolving injury

Ellenbogen – it is a traumatic brain injury, is the game worth it? No.

Panel – consensus is NO RTP same day

McCrory to Aubrey about playoff example – what about a regular season, and Aubrey is being very honest, and he feels the player push back is greater

Ken Dryden from the audience – why are we treating professional athletes different from the youth or non-elite athlete

We are starting to move away from that, all athletes should be treated the same

Should there be helmets in woman’s lacrosse and field hockey?

Cantu – yes, because of stick and ball causation of concussion

Putukian – no, change nature of the game, no reports of intercranial bleeds in women’s lacrosse, weary of unintended consequences (BTW, probably has the most experience with this)

Cantu and Putukian discussing this topic

Change gears – what about football?

Dvorak not in FIFA’s plans to recommend, many reasons including the false security of wearing head gear

Audience Q: should we discourage the use of the head bands/head gear

Dvorak – your own prerogative but data does not support the use of them as recommendation (Czech goalie wears one)

McIntosh – Rules are more important at this time

Should there be age restriction on tackling in American football, heading in soccer and checking in ice hockey?

Cantu – his words speak for themselves, youth sports needs to look at how the game is played because of the differences between older

McCrory – in Australia you cannot get to the gladiatorial aspect of Aussie Rules until they are “of age” (13 if I heard correctly)

Ellenbogen – risk of activity, most concussions via CDC information is from wheeled sports and recreation, does not make sense at this time to him, advise accordingly

Cantu – youth sports don’t have the good data, personally he does not believe learning a sport at age 5 will make you elite, it is a genetic disposition in his opinion

Putukian – it makes sense to decrease exposure, US Lacrosse has put age 13 on checking, her take on soccer is that there is no data to support this when using proper sized ball and equipment

Dvorak – young soccer players learn sport first, and fundamentals of “football” its not “headball”, studies done on heading ball and with study there was no increase in biomarkers they were looking at it. They don’t force kids to head ball until skills are sufficient.

Herring – false warranty? Arbitrary age is concerning, take head out of the game rather then taking the game away from youth athletes. The limit to exposure is accurate, but complete removal of the sport may not be necessary.

Cantu – sport needs to be safer for younger athletes

Aubrey – ice hockey has set limits on age for body checking, research is very important, it will help make decisions

Slide on difference between CTE and Alzheimer’s (note beta amyloid presence in AD)

Editorial: her slides and notes really make me question why people are questioning her work in this area, it seems about as clear as it can be, there is NO OTHER explanation in lit historically or now…

There are stages to CTE, I-IV, and some have comorbidities pathologically speaking

Discussed papers from Omalu and early discovery in Webster, Long and Waters

Incidence of CTE and CTE-MND is 4x higher in former professional football players – in a study done by death certificate research only. This research/paper only stands out to begin a frame of reference. It has a very small sample size to make assumptions. (sorry I don’t have the publication or author, I missed it)

CTE is progressive; believed to be caused by concussive and sub-concussive blows/unrecognized concussions, not prolonged PCS, not just a cumulative effect of concussions, symptoms begin years or decades after the brain trauma and usually worsens.

Determining Risk Factors

Prevention of Suicide

Credit to Robert A. Stern, PhD – does the interviews on the brain studies

Trying to get a prospective study done as opposed to retrospective

Discussed how AD dx. started and has become dx. in vivo, what they want to do with CTE

fImaging – show difference between concussed vs. non concussed fMRI most ready to be worked on – other fImaging: magnetoencephalography, near infrared spectroscopy, PET, single photon emission computed tomography

Impact sensors – not about biomechanics, more for clinical tools (possible uses)

Injury screening tool (threshold)

Impact dose monitoring

Remote medicine (telemedicine) – concerns/possible uses

Usability

Mobile devices (picture)

Education

Information utility

Diagnosis/management – who is using them, validation?

Summary: qEEG, fMRI show promise more coming on line, buckle up as more will be entering market

Benson –

Equipment is difficult to study (moving target) to many variables (Meeuwisse et al)

Measure of effect for equipment ranges from harm to no change to benefit all scientifically

Review was 2008 to 2012 – found only 3 studies (36 before date range)

Helemts/Head Gear

CYCLERS, RODEO, SKIERS, SNOWBOARDERS – yes

6 rugby studies

2 very old football studies

1 hockey study (1970)

1 soccer (2008), Delaney et al.

3 snow studies

1 rodeo

6 cycling

Mouthguards

NO DIFFERENCE SHOWN

Singh et al – football – several biases

Benson et al – hockey – no difference in concussion or time loss

Mihalik et al (2007)

Wisniewski et al (2004)

Barbic et al (2005)

Marshall et al

Finch et al (2005)

Labella et al (2002)

Facial protection (ice hockey)

NO EVIDENCE SHOWN

There is not clear evidence currently and the research needs many aspects to make sure it is validated and meets all criteria

McIntosh –

Impact dose meter or injury prevention options

Studies have been changing to in vivo because of technology (linear and angular impact with duration)

Impact and head telemetry must address all angles of attack

having helmets that reduce G’s to 150-200 in the case of most bike helmets for linear acceleration does little for concussion

angular studies are rarely addressed by current helmet systems

McIntosh feels that there is a threshold based on linear and angular acceleration for concussion

16 thoughts on “Zurich Day 2… And We Are Live”

What did Brian Benson report about updated research and publication since Zurich report from 2008 on the efficacy and injury rate reduction and concussion reduction issues with respect to helmuts and mouthguards.

Did Brian Benson reference any studies specifically on mouthguards since 2008 that were published in regards to mouthguards and concussion prevention for us to read about?

Does he think that any old school mouthguards such as what most high school kids wear (those ones that are always falling out their mouths types) or those newer pressure laminated mouthguards such as what NBA, NFL and top College teams are wearing (where they look like they just stay in place better) may be able to play a role in concussion prevention and further studies should be done?

OR FINALLY

Is it just not necessary to further evaluate different types of mouthguards as it has been finally concluded and validated in the updated reaseach papers since 2008 on mouthguards that it is impossible for mouthguards to actual play any role in concussion prevention?

OR IF NOT
Did he recommend how reseachers would go about the criteria needed researching the different types of mouthguards in regards to concussion evaluation to be able to come to a validated conclussion about mouthguards as a prevention piece of protective equipment beyond its primary purpose to protect teeth?

Hope blog readers don’t mind me making a brief comment re Super Storm Sandy. If you think this response should be placed elsewhere, Dustin…please do so.

My wife and I reside in the northeast and family members have been adversely impacted by Super Storm Sandy.

Given the loss and related grief many individuals and families are presently facing…below are 2 National Association of School Psychologists’ (NASP) resource links with helpful tips on what do after a natural disaster such as Sandy. Please share with others.

What knee jerk, you must be tired from your flight. Actually since you have this audience of experts. Can you ask them, “what is temporal mandibular joint dysfunction and what specific role does it play in symptom related issues? Follow up would be, have you had any training in Temporal Mandibular Joint Dysfunction and what can be done to help protect against the “glass Jaw” effect.

Abstract;

Traumatic brain injury (TBI), often caused by shock waves from blasts, has been called the “signature wound” of the wars in Iraq and Afghanistan. Commonly, the deleterious effects on the blast are compounded by the extra forces transmitted to the skull from the jaw through the temporomandibular joint (TMJ). In contact sports, it has been shown that mouth guards can be effective in reducing concussions and mild TBI. This proposal describes how a Massachusetts company., in collaboration with Dr. Robert Cantu of Boston University Medical Center and Emerson Hospital, a world-renowned authority on neurology and sports medicine, will develop an appliance to mitigate concussive forces associated with high-energy blasts. In Phase I, potential materials and relevant existing devices, particularly athletic mouth guards, will be researched for their application to a product that could be used by the military. Initial design concepts will be worked out based on this research. In the Phase I Option, more concrete models will be made as a precursor to an in-depth commercialization plan to be addressed in Phase II.

Why is CTE found primarily in the Medial Temporal Lobe, just millimeters from the TMJ. Why is there not more research, like the ARMY’s, focused on this region/mechanism? Nothing about orthodontic mouth guards or selling. Just the facts. Aside from Dr. Benson, there is probably not one TMD expert in Zurich, find a qualified one and I will pay for your flight next year.

The evidence in Military subjects, blast injury, shows not only is frontal lobe affected but also the white matter damage that is not experienced in civilian injuries. UCL confirmed this in a well designed study presented recently in New Orleans.

Mouth guards will do very little if anything in people exposed to blast.

Temporomandibular Joint Dysfunction is just that. In no way does TMJ=Concussion or Concussion=TMJ. TMJ elicits similar symptoms to concussion due to forces exerted on cranial nerves, muscles and structures, but TMJ does not affect the brain. Concussion does as it is a “Traumatic Brain Injury”.

As Dustin has said TIME AND TIME again is that mouth guards have been greatly proven to protect against mouth and TMJ injuries. What they have not been proven to do is prevent concussions. Thus making your statement “In contact sports, it has been shown that mouth guards can be effective in reducing concussions and mild TBI.” scientifically false at this point. Did you not hear about a certain mouthguard company being fined for trying to say that their product did just that?

Yes athletes should wear mouthguards and probably soldiers should have something similar, but that and “protecting against concussions” are two totally different realities.

“TMJ elicits similar symptoms to concussion due to forces exerted on cranial nerves, muscles and structures”

TMD is a completely different set of circumstance related to the lower brain stem/cervical spine, that needs its own focus of research and classification of injury. No protocol is in place to measure the degree of manipulation or positioning needed to the cervical spine or jaw in those with TMD. BRain pad mouth guards do nothing but arbitrarily position the jaw with no science, dental training or protocol, hell you fit them over your kitchen sink. Orthodontic and neuromuscular appliances are made to strict dental/medical standards. This is just an advancement of technology in oral appliances for those with orthotic needs, just like orthotic ski boots for those with foot issues. Just as you have seen in the helmet industry, these advancements are documented and recognized by U.S. Army research, the ADA, and the CDC, yet no mention of any extended research by any large institution or governing body, only the Army in collaboration with Dr. Cantu. Concussion symptoms from a cerebral event are a completely different set of circumstances and not related to TMD in athletes. Blows to the jaw and whiplash, needs more focus in relation to this theory put forth to the military by Dr. Jeffery Shaefer a Harvard MGH expert.
The question remains, is the micro trauma experienced, such as dings, dizziness, the sensation of seeing stars and nausea, which is often shaken of and ignored. Is this what is causing CTE and not the major concussive blow to the top of the head. Here’s the smoking gun, CTE is found exactly millimeters from where this jawbone trauma occurs, not the top of the head. Boxers dementia, the boxers glass jaw, what role does this play in the development of CTE. More focus, that is what we are advocating for, yet none, at FIFA.

TMJD is not Concussion… Migraine is not concussion… Tension headaches are not concussions… Dehydration is not concussion… Hypoglycemia is not concussion…

Guess what they all have similar or overlapping symptoms… There is no way in heck that mouthguards can protect against concussions, period… Not only is it impossible due to Physics it is also scientifically PROVEN that they do not, PERIOD…

You keep asking me to prove a negative… How about this you prove to me and the audience how and why your product, made by Maher Co. (putting this in here so when the FTC looks, and they do), will protect against concussions…

In fact I will gladly post and forward your information and claims to Washington DC so it gets to the right people…

Just like FIFA stated yesterday in regards to head “bands/gear” for soccer, there is no data to suggest they help in any fashion, therefore FIFA does not recommend or suggest their usage…

TMJD is not Concussion… Migraine is not concussion… Tension headaches are not concussions

We are not claiming concussion prevention, what the Army is investigating is, what role does TMD have in micro trauma, not concussion. Does micro trauma, dings, nausea, headache, dizziness, have a role in the development of CTE, not concussion. We know subjects with TMD report a much higer rate of these microtrauma symptoms.

One case, the U Penn player that was diagnosed with CTE, yet never reported one concussion. Did the micro trauma cause his CTE. Was it the small “events” accumulating time and time again. How prevalent are these symptoms in every player in every sport. Why does it only occur in some athletes and how can we better prepare athletes from this. These are questions that need to be answered.

Not even helmets can be promoted as preventing concussion. Yet they have been investigated by researchers to the end. Cantu has stated, you can’t improve them much more than they already are with out making them oversized and they are only designed to prevent skull fracture. This TMD, temporal bone, brain stem region the Army has funded research of, needs more outside attention, because it is exactly where CTE originates. The jaw, TMJ area is part of the head last time I checked, Yet, there is probably no discussion of this in Zurich and I would be shocked if you could find one expert there that would be qualified to dispute Dr. Jeffery Shaefers findings.

The hypothesis is that yes it was a cumulative effect in Owen Thomas’s case, however CTE was not the reason he took his life… Microtrauma symptoms are completely unknown from a scientific perspective, Cantu spoke on them… Again TMD and concussion or any brain issue will and does have overlapping symptoms

No helmets prevent concussions, none say they do…

I want this clear for all to read… You, Mark Picot of Maher Lab Co., is hypothesizing that the mandible crashing (if it actually does) into the base of the temporal portion of the skull (again not sure if it does with enough force to translate to the brain sitting beyond the bone and CSF) causes CTE?

You, Mark Picot of Maher Lab Co., is hypothesizing that the mandible crashing (if it actually does) into the base of the temporal portion of the skull

I can’t take credit for what a Harvard expert and the U.S. Military have undertaken.

To explain in more detail, the paper-thin bone separating the end of the jawbone and the brain or medial temporal lobe, is paper thin. TMD occurs when the dime sized cartilage disk, which sits in that pocket of paper-thin bone, slips out of place. This slipped meniscus leaves that area vulnerable to receive direct forces to the medial temporal lobe. This condition is diagnosable and has a certain set of symptoms recognized by the ADA and CDC. It is a completely different injury and mechanism of head injury compared to Cou contra Cou. The link below shows the disk on blue when it is in its natural protective position. Protecting the skull base, nerves, brain stem and paper thin bone. Many candidates with this condition are post orthodontic or have had some type or jaw injury, hence the boxer’s glass jaw. Why do only some of these athletes become prone to the symptoms of dings, dizziness, nausea, inner ear issues, micro trauma not concussion.

Force received on the chin, chin strap, radiates to the temporal bone, traumatizing the TMJ and surrounding area. When out of alignment, damaging the meniscus disc, more severe symptoms and ongoing issues have been found in many NFL, NHL and NBA player. Not to mention scores of high school, college and U.S. Army soldiers.
This theory, backed by Dr. Shaefer, Army doctors is the basis of the Army grant
More focus is needed, is this to much to ask?

The last time we went over this, you were ok with the Tmd/orthodontic approach. What has changed.

Renee RobertsNovember 25, 2012 / 08:51

Is there anyone on here that can help me find a support group for what our doctor is calling
POST CONCUSSION SYNDROME /CTE. My husband suffers from bouts of anger, agression, confusion, and depression. This is the short list, learning how to prevent in great, but what about the people who are trying to survive with Doctors who don’t have a clue how to help those of us who are trying to manage day to day life with someone that suffers from this condition. He played high school and college football and a severe concussion from a fall from an 18ft ladder on to a concrete floor.
Any HELP or ADVISE would be helpful!

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